In the name of God

1. In the name of God

2. Child Maltreatment(Child Abuse) H Fanian MD

3. Definition of Child Maltreatment Center for Disease Control & Prevention (CDC) Any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child

4. Journal of Child Abuse and Neglect Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation

5. Child Abuse that Occurs in Medical Setting(Munchhausen Syndrome by Proxy) An adult caregiver either makes a child appearsick by fabricating symptoms, or actually causes harm to the child, in order to gain the attention of medical providers and others Medical assessment of vague illness Multiple diagnosis Therapeutic procedures for unclear reasons

6. Distinction between child discipline or physical punishment, and abuse is often poorly defined

7. Incidence of Child Abuse An international phenomenon 4 million cases annually in US, including 2000 death 6000 emergency calls annually in Iran (out of 144000) Tip of the Iceberg Non-reported & un-diagnosis

8. Risk Factors of Child AbuseChild abuse is a complex phenomenon with multiple causes Marital separation, job loss, family death, unintended pregnancies, financial difficulties, Substance abuse (alcohol, cocaine, heroin,….) Nonrelated adult living in the household Stepparents, babysitter, boyfriends, relatives Prematurity, congenital anomalies, medical fragility …

9. Effects of ChildAbuse Guilt, nightmares, insomnia Fear of things associated with the abuse (including objects, smells, places, doctor's visits, etc.) Sexual dysfunction Chronic pain, addiction, somatic complaints Self-injury, suicidal Depression, PTSD, anxiety

10. After 30 years Bentley and Widom (2009) found that physical abuse during childhood is a risk factor for obesity in adulthood

11. Major Categories of Child Abuse(Child abuse can take several forms) Neglect 54% Physical 22% Sexual 8% Psychological or Emotional 4% Other forms 12%

12. Child Neglect Failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm Lack of attention from the people surrounding a child

13. Observable Signs in a Neglected Child Frequently absent from school Begs or steals food or money Lacks needed medical and dental care Consistently dirty Lacks sufficient clothing for the weather Delays in physical and psychosocial

14. Child Sexual Abuse A form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation In US, approximately 15% to 25%ofwomen & 5% to 15% of men were sexually abused during childhood Child-on-child sexual abuse?

15. Physical Abuse Child Including hitting with a hand, stick, strap, or other object; punching; kicking; shaking; throwing; burning; stabbing; or choking to the extent that demonstrable harm results

16. Injuries vary greatly from mildredness on the buttocksthat fades over several hours, to injuries so severe, that the child dies

17. Physical Abuse in Children 1-3 years (34%) 4-7 years (23.4%) 8-11 years (18.7%) 12-15 years (17.3%) 16-17 years (6.2%) Children younger than 1 year had the highest rate of victimization overall

18. Orthopedist & Child Abuse 30% to 50% of abused children visited by an orthopedist, if unrecognized, 25% risk of serious re-injury, & 5% risk of death Prepare records as thought everything will be reviewed & read in court Photographs taken to document skin lesions must be done before cast placement

19. Types of Physical Injures in Child Abuse Bruises Burn Fracture Head injuries Internal injuries

20. Distribution of Abuse & Accident Bruising

21. Burns in Child Abuse Hot liquid, hot object, chemical, electrical Force to drink a cleaning fluid for punishment

22. Central Nervous Systems Injuries Subdural hematoma (SDH) Abusive head trauma (AHT) Shaken baby syndrome (SBS) /shaking-impact syndrome

23. Love Me…..Never Shake Me Shaken Infant Syndrome

24. Abdominal Injuries in Physical Child AbuseSecond most common reason for death

25. Abdominal Injuries in Physical Child AbuseSecond most common reason for death Liver Stomach Pancreas Spleen Kidney Duodenum

26. Fractures in Abused children(11% to 55%) second after skin lesions Rib, extremity, & skull Femoral fracture in children <1 year of age are commonly due to abuse

27. Investigative interview What happened When Where Who was there Child position before injury How the child reacted How caregiver promptly does ………..

28. 165 Infants Fatality with Fracture due to Child Abuse (13 skull Fx)

30. No “babygram” 58% of fractures were seen Fractures can be missed on digitalized images Repeat skeletal survey in 2 weeks

31. Mechanism of Rib Fractures in Child Abuse 1: squeezing of the chest by a caretaker 2: hitting the child from behind 3: stepping on the chest Nondisplaced & can be very difficult to diagnose acutely

32. Posteromedial Multiple Rib Fractures with Callous Formation in a 6-month-old Child

33. Classic Metaphysial Lesions

34. Corner Fracture First described by Caffey Small piece of bone is avulsed due to shearing forces on the fragile growth plate These fractures are often subtle, and the likelihood of detection is directly related to the quality of the radiologic studies

35. MetaphysialCorner Fractures

36. Bucket Handle Fractures These fractures are essentially the same as corner fractures. The avulsed bone fragment is larger and seen 'en face' as a disc or bucket handle. These corner and bucket handle fractures are most common in the tibia, distal femora and proximal humeri. They are frequently bilateral.

37. Bucket Handel Fractures

38. Bone Healing & Dating of Injuries Dating of boney injuries is particularly important in the evaluation of physical abuse, because it may assist investigators in determining who had access to the child in the period the injury is estimated to have occurred.

39. Dating Fractures Orthopedist often is asked to determine the age of fracture Periosteal reaction appears at about 14 days Not all classic metaphyseal lesions develop visible callous Skull fractures generally cannot be dated Bone scan are not useful for dating of fracture

40. Metatarsal Fractures in a 2-month-old Female Victim of Nonaccidental Trauma

41. Differential Diagnosis of Physical Child Abuse (skin lesion) Mongolian spots Hemangioma Eeczema Phytophotodermatitis Erythemamultiforme Bleeding disorders ……

42. Differential Diagnosis of Child Abuse (Radiographyically) Osteogenesisimperfecta Caffey's disease (infantile cortical hyperostosis) Metaphyseal dysplasia Vit D deficiency Scurvy ……..

43. Bruising & Bilateral Distal Femoral Fractures due to Scurvy

44. Prevention of Child Abuse April is national child abuse prevention month Blue ribbon against child abuse Child protective services team Home visitor programs

45. Thank You for Your Attention

46. PediatrEmerg Care. 2012 Dec;28(12):1366-8 Increased serum creatine phosphokinase in a child with bruising due to physical abuse Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis

47. Psychological &Emotional Abuse Production of psychological and social deficits in the growth of a child as a result of behavior such as loud yelling, coarse and rude attitude, inattention, harsh criticism, and denigration of the child's personality